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Vermont and the ACA’s Medicaid expansion

Both candidates for governor would preserve Medicaid expansion

vermont Medicaid guide

Vermont has fully embraced the Affordable Care Act (ACA), including the expansion of Medicaid. The state’s Medicaid enrollment has grown by 11 percent since the end of 2013. But Vermont already had state-subsidized health care plans for low-income residents, and many of the newly-eligible Medicaid enrollees were previously insured under a state-run program.

The state’s uninsured rate prior to ACA implementation was much lower than the national average — only 7.2 percent according to U.S. Census data. By 2014, it had fallen to 5 percent, and by 2015, it had dropped even lower, to 3.8 percent — tied with the District of Columbia for the second-lowest uninsured rate in the country, trailing only Massachusetts.

2016 election — new governor will preserve Medicaid expansion

About one out of every three residents in Vermont is covered by Medicaid, a per-capita percentage that’s the second-highest in the country. While that has certainly helped drive the state’s uninsured rate down, it’s also caused some lawmakers to question whether such a high percentage of residents being on a program designed to help low-income residents is something the state should be addressing in other ways, such as creating more high-paying jobs so that people can transition off Medicaid.

Governor Peter Shumlin is not running for re-election in 2016. The two candidates vying to replace him — Democrat Sue Minter and Republican Phil Scott — both support keeping Medicaid expansion in place. Scott’s health care proposal includes plans to reduce Medicaid administrative costs and work with the federal government to obtain a federal safety net for long-term care. Minter noted that while the high percentage of state residents on Medicaid is not something to celebrate, she’s “grateful we have a program” for covering folks who would otherwise be uninsured.

Who is eligible?

Medicaid is available for these legally present Vermont residents:

  • Adults with incomes up to 138 percent of poverty
  • Children with household incomes up to 312 percent of poverty
  • Pregnant women with incomes up to 208 percent of poverty.

How do I apply?

In Vermont, Medicaid is called Green Mountain Care, and the program for children and pregnant women is called Dr. Dynasaur. Applications are completed through the state-run exchange, Vermont Health Connect.

If you have questions, you can call the Vermont Medicaid office for assistance at 1-800-250-8427.

All-payer model receives tentative approval

Vermont has long been a vanguard when it comes to healthcare reform. And although the state abandoned their push for a single-payer system in late 2014, they’ve moved forward with their plans for an all-payer model that would merge payments from Medicaid, Medicare, and commercial insurers, paying set rates to all providers in the state via what would essentially be one big accountable care organization. In September 2016, Vermont received tentative approval from CMS for the waiver that would be needed to coordinate Medicare (whcih is a federal program) into the all-payer model.

Medicaid spending drives budget shortfall

Vermont’s budget is expected to have a $58.5 million shortfall in Fiscal Year 2017, which started in July 2016. That will be the ninth year in a row that the state’s spending has outpaced revenue. State officials briefed lawmakers December 2015, explaining that the state was facing a budget shortfall of $40 million in the 2016 fiscal year, and that it would grow to nearly $59 million in the next fiscal year. But the good news is that the state was expecting their budget shortfall in FY 2017 to be about $10 million more than they’re now projecting.

$53 million of the projected FY 2017 shortfall is attributed to Medicaid spending. And $36 million of the current fiscal year’s $40 million shortfall is due to Medicaid spending. The federal government is paying the full cost of expansion through the end of 2016, but the state will have to begin paying 5 percent of the cost of covering the newly-eligible population starting in 2017. In addition, the outreach and enrollment efforts in every state have resulted in people enrolling for the first time in Medicaid despite the fact that they already qualified under the pre-ACA eligibility guidelines. For this population, the states are on the hook for their normal funding split with the federal government.

Governor Shumlin proposed a payroll tax in January 2015 (0.7 percent) to provide additional funding for Medicaid, but lawmakers balked at the idea.

In an effort to rein in spending, Vermont’s Medicaid program began going through eligibility redeterminations for existing enrollees starting in October 2015. Roughly a third of Vermont’s population is on Medicaid, and officials believe that some are not actually eligible for the coverage. The eligibility verifications have been ongoing throughout 2016, and the state has determined that some young adults have been incorrectly enrolled in Dr. Dynasaur rather than expanded Medicaid (which is fully funded by the federal government through 2016) or individual market coverage with subsidies through the exchange.

How many people have enrolled?

According to Vermont Health Connect enrollment reports, total Medicaid enrollment (adult plus child) through the exchange was 131,993 in December 2014, and had increased to 141,173 by June 2015. Total Medicaid enrollment in Vermont stood at 187,174 by August 2015.

As April 2014, Vermont Health Connect reported that 67,187 people were enrolled in the state’s expanded Medicaid program, although they noted that approximately 8,000 of those individuals had been previously enrolled in Medicaid and had renewed their coverage through Vermont Health Connect.

The exchange reported that more than 33,500 people were automatically transferred from one of the state’s pre-2014 subsidized health plans (Catamount and VHAP) to expanded Medicaid as of January 2014.

In all, 55 percent of Vermont Health Connect’s applicants qualified for Medicaid during the first open enrollment period (October 2013 to April 2014).

The decision to expand Medicaid

Although Vermont was quick to accept federal funding for Medicaid expansion as called for in the ACA, the state had already addressed the issue of health insurance for low-income residents, nearly two decades earlier.

In 1995, the Vermont legislature authorized the creation of Vermont Health Access Plan (VHAP) and Dr. Dynasaur, which is still utilized to provide coverage to children and pregnant women. Dr. Dynasaur provided coverage to children with household incomes up to 300 percent of poverty, pregnant women with household incomes up to 200 percent of poverty, and for parents and guardians with incomes up to 185 percent of poverty.

VHAP provided coverage for other adults with household incomes up to 150 percent of poverty.

In addition, in 2006, the state created Catamount Health, which allowed residents with incomes up to 300 percent of poverty to purchase a Catamount plan (provided be either MVP Health or Blue Cross Blue Shield) at a subsidized rate.

As a result of Vermont’s early health care reform, the state’s uninsured rate in 2005 was just 9.8 percent – far lower than the national average of 15.7 percent.

Catamount and VHAP were scheduled to end on December 31, 2013, with all of their insureds switching over to either expanded Medicaid or a subsidized private plan through the exchange.  But because of Vermont Health Connect’s rocky rollout, Governor Shumlin extended Catamount and VHAP until March 31, 2014 for any residents who were still enrolled in those plans.

Medicaid eligible residents were able to begin submitting applications on October 1, 2013, with expanded Medicaid policies effective January 1, 2014.

No single payer system, but reform still priority

Vermont was originally on a path towards a single-payer health care system starting in 2017, but they abandoned that effort in December 2014, citing higher-than-expected costs. The state is still pushing forward with efforts to further reform its health care system and limit overall health care spending growth. In November 2015, state regulators briefed lawmakers on their plans for an all-payer model agreement with the federal government. The state wants to take control of Medicare in addition to Medicaid, and limit healthcare spending growth to 3.5 percent for the whole population of Vermont.

Vermont Medicaid

How to apply

Apply for Green Mountain Care and Dr. Dynasaur through Vermont Health Connect.

Who is eligible

Adults with incomes up to 138% of FPL; children with household incomes up to 312% of FPL; pregnant women with incomes up to 208% of FPL.

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